THE RELATIONSHIP OF SPIRITUALITY AND SELF …ufdcimages.uflib.ufl.edu/UF/E0/00/83/86/00001/mcnally_p.pdf · THE RELATIONSHIP OF SPIRITUALITY AND SELF-HEALTH ASSESMENT IN PREDICTING

THE RELATIONSHIP OF SPIRITUALITY AND SELF-HEALTH ASSESMENT IN

PREDICTING POSTOPERATIVE PAIN AND ANALGESIC USE

By

PATRICIA A. MCNALLY

A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT

OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY

UNIVERSITY OF FLORIDA

2004

Copyright 2004

by

Patricia A. McNally

To my family.

iv

ACKNOWLEDGMENTS

There is no adequate way to thank my children, Jimmy, Meghan and Kerry. for all

of their support and love during my doctoral studies. I could not have completed this

work without their belief in me, the frequent phone calls, visits, and words of

encouragement. Lastly, I hope my grandchildren may you love and appreciate the

educational process with the wonder that I have experienced throughout my lifetime.

I would also like to thank my supervisory committee for their knowledge, guidance

and encouragement in supporting me. Especially, I would like to thank Sharleen

Simpson, my chair. Her constant patience and guidance and belief that “you can do this”

gave me such support throughout this doctoral process. Additionally, thanks go to

Hossein Yarandi for his valuable assistance in analyzing data, and to Dr. Donald Caton, a

teacher and friend, who has been a leader in relieving pain. Through his example, he

brings out the best in all of us. Finally, thanks go to Dr. Monika Ardelt who has pursued

research that includes the study of spirituality and geriatrics. I will always be indebted to

all of them for their direction.

I am grateful to Dr. Peter Gearen, Chairman, Orthopaedic Department, and Dr. Nik

Gravenstein, Chairman, Anesthesia Department, for their support in designing and

implementing this research. Additionally, I want to thank the Pre-Surgical Center

administration for supporting the importance of this research and providing access to

patients.

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TABLE OF CONTENTS page ACKNOWLEDGMENTS ................................................................................................. iv

LIST OF TABLES........................................................................................................... viii

ABSTRACT....................................................................................................................... ix

CHAPTER

1 INTRODUCTION ........................................................................................................1

Background and Significance .......................................................................................3 Chronic Pain in the Older Adult ............................................................................3 Osteoarthritis and Chronic Joint Pain in the Older Adult......................................4 Total Joint Arthroplasty in the Older Adult ..........................................................5 Spirituality in Older Adults ...................................................................................5

Summary.......................................................................................................................7 Specific Aims................................................................................................................7 Terminology .................................................................................................................8

2 REVIEW OF THE LITERATURE ............................................................................10

Presence of Musculoskeletal Chronic Pain and Arthritis Among Older Adults ........10 The Relationship of Background Contextual Stimuli and Pain..................................11

Age, Pain, and Osteoarthritis...............................................................................11 Gender, Pain and Osteoarthritis...........................................................................12 Age, Gender, and Osteoarthritis ..........................................................................12 Race, Pain and Osteoarthritis ..............................................................................13

Total Joint Arthroplasty..............................................................................................14 Prevalence............................................................................................................14 Gender and Arthroplasty .....................................................................................15 Race and Arthroplasty .........................................................................................16 Spiritual Coping...................................................................................................16 Spiritual Coping and Health ................................................................................18 Relationships between Spiritual Beliefs, Gender and Race ................................21 Roy Adaptation Model-Based Research .............................................................22 Roy Adaptation Model Gerontologic Research ..................................................23

Summary.....................................................................................................................24

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3 METHODS.................................................................................................................25

Research Design .........................................................................................................25 Controls ...............................................................................................................25 Power Analysis and Sample Size ........................................................................26 Procedures ...........................................................................................................26 Protection of Human Subjects .............................................................................27 Method.................................................................................................................27 Measures..............................................................................................................28 Preoperative Questionnaire Measures .................................................................28

Indicator of spirituality.................................................................................28 Indicator of self-health assessment ..............................................................28 Indicator of ethnicity ....................................................................................29

Postoperative Data Collection Procedures ..........................................................29 Data Analysis..............................................................................................................31 Summary.....................................................................................................................32

4 RESULTS...................................................................................................................33

Sample Characteristics ........................................................................................33 Regional Anesthesia ............................................................................................34 Anesthesia Technique During Surgery................................................................34

Analysis of Data in Relation to the Hypotheses .........................................................35 Hypothesis 1 ........................................................................................................35 Hypothesis 2 ........................................................................................................35 Hypothesis 3 ........................................................................................................36

Additional Findings ....................................................................................................36 The Short Form-36 Health Survey .............................................................................37

5 DISCUSSION.............................................................................................................45

Research Findings.......................................................................................................45 Sample Characteristics ........................................................................................45 Impact of Health Assessment and Spirituality on Pain Reports and Analgesic

Medication Use ................................................................................................48 Conclusions.................................................................................................................48

Strengths and Limitations....................................................................................49 Implications for Nursing Practice and Future Study ...........................................50

APPENDIX

A LETTER OF AGREEMENT......................................................................................53

B INFORMED CONSENT 08-19-03 TO 07-15-04 ......................................................55

C INFORMED CONSENT 01-29-04 TO 07-15-04 ......................................................63

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D INFORMED CONSENT 07-16-04 TO 07-15-05 ......................................................71

E THE SHORT FORM-36 HEALTH SURVEY—SPIRITUAL INVOLVEMENT AND BELIEFS SCALE .............................................................................................78

LIST OF REFERENCES...................................................................................................87

BIOGRAPHICAL SKETCH .............................................................................................92

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LIST OF TABLES

Table page 1 Frequency and Percent of Variables.........................................................................38

2 Summary Measures of Variables .............................................................................39

3 Pearson Correlation Coefficients-Spirituality and Variables with No Adjustments..............................................................................................................39

4 Pearson Partial Coefficients-Controlling for Health Assessment ............................39

5 Pearson Correlation Coefficients-Health Self-Assessment and Variables with No Adjustments..............................................................................................................40

6 Pearson Partial Coefficients-Health Self-Assessment and Variables Controlling for Spirituality ..........................................................................................................40

7 Frequencies and Percentages for Self- Reported SIBS Questionnaire (N=115). .....41

8 Frequencies and Percentages Questions that Indicated Ratings for General Health, and Bodily Pain as Self-reported on the Short Form-36 Health Survey questionnaire (N=115)..............................................................................................43

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Abstract of Dissertation Presented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy

THE RELATIONSHIP OF SPIRITUALITY AND SELF-HEALTH ASSESSMENT IN PREDICTING POSTOPERATIVE PAIN AND ANALGESIC USE

By

Patricia A. McNally

December 2004

Chair: Sharleen Simpson Major Department: Nursing

The purpose of this descriptive study was to investigate relationships between

spirituality and self-heath with three postoperative outcomes after total hip or knee

arthroplasty in the older adult.

A total of 115 subjects between the ages of 55 and 86 years of age (M = 67.8) who

met the inclusion criteria were enrolled in this study. Forty-one were male and seventy-

four were female. One question from the Spiritual Involvement and Beliefs Scale and

one question from the Short Form-36 Health Survey were used to measure spirituality

and self-health assessment. Operative site, average daily pain scores, median daily pain

scores and analgesic medication use data were obtained from the patient’s medical record

for three days postoperatively.

Bivariate analysis found that those participants with a high degree of spirituality

did not report less pain on days one (r = 0.01, p = 0.92), day two (r = 0.02, p = 0.84) or

day three (r = 0.03, p = 0.78). They also did not use less analgesic medication during the

x

three postoperative days (r = -0.04, p = 0.69). However, those participants who self-

assessed their health as good to excellent did have less pain on day one (r = 0.31, p =

0.00), day two (r = -0.29, p= 0.00) and day three (r = -0.22, p = 0.02). There was no

reduction in analgesic medication use (r = -0.11, p = 0.25). An ANOVA regression

found there was no relationship for a high degree of spirituality, a high self-health

assessment and the use of less pain medication (F = 1.04, p = 0.38).

The study supported the hypothesis that older adults who rate their self-health as

good, very good or excellent experienced less postoperative pain but this study did not

support less pain medication use. Second, this research did not support the hypothesis

that a participant’s spirituality influences pain or analgesic medication use after

arthroplasty surgery. Third, a high degree of spirituality and good health together did not

make a difference in the amount of analgesic medication used for pain control.

The majority (81.7%) of the participants felt their health was good, very good or

excellent. Second, most (67%) indicated they were highly spiritual and 70% felt that

spiritual health contributes to physical health. Finally, the majority of the respondents

believe in spiritual coping behaviors such as prayer, belief in an afterlife and a personal

relationship with a greater power.

This research found that an individual who rates their self-health as good, very

good or excellent has less pain after arthroplasty surgery, but this self-health assessment

does not influence the use of pain medication. Although participants considered

themselves “highly spiritual”, their spirituality did not influence postoperative pain or

pain medication use.

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CHAPTER 1 INTRODUCTION

The increased number of aging persons has stimulated researchers to define the

concept of aging as viewed by older adults in our society. Rowe & Kahn, (1998) define

successful aging as the avoidance of disease and disability, social involvement and high

level of cognitive and physical function. Success, according to their definition, includes

few physical limitations, health, and the absence of chronic pain. Most adults over 55 yrs

of age do not report problems with daily activities such as: walking, bending and

stooping without assistance. In this age group, however, chronic pain can limit the level

of functional activity. A chief cause of chronic pain and disability among adults over 55

is osteoarthritis

The experience of chronic pain in the elderly is both a physiologic and emotional

experience. Although rooted in sensory stimuli, pain also has an important overlay from

an individual’s culture and experience (Porter, et al. 1996). Among all age groups pain

can be defined as an experience with both a sensory and emotional component, but for

the elderly adult, pain may signify a chronic condition that is not always managed

effectively with drug treatment. The most frequent cause of chronic pain and total

disability reported by the older adult is arthritis (Affleck, et al. 1999; Felson, 1988;

Mobily, Herr, Clark, & Wallace, 1994; Praemer, Furner & Rice, 1999; Schlesinger,

2001).

The American Geriatrics Society suggests using both pharmocologic and non-

pharmocologic methods to achieve a greater degree of pain relief (American Geriatrics

2

Society, 1998; Gagliese & Melzak, 1997). Non-pharmocologic methods of pain control

include massage, acupuncture, and behavioral therapy. Keefe, et al. (2000) in a study of

rheumatoid arthritis and joint replacement, found that effective coping strategies included

praying, hoping and calming self-statements.

Research on the relationship of spirituality and health has gained increasing interest

in the academic and popular press over the past 15 years. Most early research used

retrospective data analysis to study the effects of religious affiliation, and hypertension,

depression, mortality, and anxiety (Clark, Friedman, & Martin, 1999; Husaini, Blasi, &

Miller, 1999; Koenig, George, Blazer, Pritchett, & Meador, 1993; Koenig, George,

Meador, Blazer, & Dyck, 1994). They observed a positive correlation between church

attendance and various correlates, such as hypertension, depression, anxiety, hospital

length of stay, and mortality (Koenig, et al. 1993; Koenig & Larson, 1998; Meador, et

al.1992).

Levin and Chatters (1998) suggest future quantitative studies to evaluate

relationships between spirituality and health. Although older people may rely more on

defensive coping strategies, the possibility that spiritual coping mechanisms may have a

therapeutic effect has not been explored. Such spiritual coping mechanisms might

include prayer, religious service attendance, and seeking a spiritual connection (Ellison &

Levin, 1998; Koenig & Larson, 1998; Pargament, Smith, Koenig, & Perez, 1998). These

studies suggest that older adults who use spiritual coping methods during stressful

medical conditions have a more positive health outcome.

I wished to explore the effect of spiritual belief, spiritual behavior and health self-

assessment on the response to postoperative pain. Towards this end I examined the

3

relationship between specific assessments of spiritual behavior, health self-assessment, to

reports of pain report and the use of analgesic medications among a group of older adults

recovering from hip replacements surgery.

Background and Significance

Chronic Pain in the Older Adult

Pain is defined as a noxious physical and emotional experience. Although similar

for all age groups, elderly adults appear to have a higher incidence of chronic pain. The

only measure of the presence and intensity of pain is the report of the person

experiencing the pain (Ferrell, 2000). Nociceptor pain, including chronic pain, begins

with the activation of special receptors and afferent fibers by peripheral stimuli usually

associated with processes involving tissue damage and inflammation (Ekblom & Rydh-

Rinder, 1998). Such pain may include musculoskeletal pain, ischemic pain, visceral pain,

and myofascial pain. There is little empirical evidence that biological or physiological

measurements correlates to the degree of pain expressed by the elderly individual

(Gagliese & Melzack, 1997). In other words, to a large extent the ‘experience’ of pain is

subjective.

Among the elderly, research indicates that more than 90% of the elderly experience

pain in the musculoskeletal system (Anderson, Ejlertsson, Lenden & Rosenberg, 1993).

Chronic arthritic joint pain begins in the upper extremities such as shoulders and then

progresses to the lower extremity as an individual ages (Anderson, et al. 1993; Mobily ,

et al. 1994). This site of the pain can greatly affect severity of chronic pain as well as the

degree of functional impairment.

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Osteoarthritis and Chronic Joint Pain in the Older Adult

Osteoarthritis is the most frequent cause of end stage joint deterioration and chronic

pain in the elder adult. In the early stage, there is only a pathologic loss of cartilage. As

the disease advances joint cartilage and underlying bone are affected, with a total loss of

cartilage and joint space. Joint cartilage serves two functions: 1) smooth frictionless

surface movement of articulating bones, and 2) transmission of the weight bearing load.

Additionally, extensive tissue inflammatory changes surround the affected joint and

contribute to the limitation of joint range of motion and severe chronic pain (Schlesinger,

2001). Visible osteophytes or lateral outgrowths of bone in the joint margins add to an

increased sclerosis of underlying bone that contributes to an additional increase in

functional impairment (Felson, 1988; Schlesinger, 2001). This loss of the articular

cartilage can be demonstrated radiographically as a joint space narrowing and

occasionally, osteophyte formation. The most frequently affected joint locations are

knees, hips, fingers, and spine (Praemer, et al. 1999).

Measurement of the impact of arthritis includes two parameters: disability or

functional impairment and economic health care system impact. The adult person 65

years of age with arthritis may have more limitations of activity than those afflicted with

other chronic disease states such as cardiac disease, diabetes, and cancer. It has been

estimated that 50% of those persons 65 years of age and older experience activity

limitation from the chronic pain of osteoarthritis (Mobily, et al. 1994). The failure of

conservative medical management, such as medications and physical therapy, in the

treatment of end stage joint osteoarthritis, has increased the demand for surgical total

joint replacement.

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Total Joint Arthroplasty in the Older Adult

The early 21st century has been declared the “Bone and Joint Decade” by 35 nations

and 44 states. Currently, more than 425,000 total joint replacements are performed each

year in the United States, and this number is expected to reach 702,000 by the year 2030

as the baby boomer generation ages (Praemer, et al. 1999). The increase in the number of

aging Americans, the increase in the prevalence of arthritis for this age group, and the

desire to remain active have added to the increase in demand for total joint replacement

surgery (Healy, Iorio, & Lemos, 2001). Joint replacement surgery has been documented

to improve pain, functional ability, social function, and quality of life for the recipient

(Aarons, Hall, Hughes, & Salmon, 1996; McGuigan, Hozack, Moriarty, Eng, &

Rothman, 1995; Norman-Taylor, Palmer, & Villar, 1996; Ritter, Albohm, Keating, Faris,

& Meading, 1995).

These findings demonstrate that osteoarthritis among older adults is a major cause

of chronic pain and functional impairment. Total joint replacement offers the older adult

pain relief and improved functional ability, particularly when there is failure with

conservative therapies.

Spirituality in Older Adults

Behavioral management of pain includes the strategy of active coping. Spiritual

coping behaviors that include praying and church attendance have been recognized as

active coping behavioral strategies used often by older adults (Koenig, et al. 1998).

Burkhardt, (1989) defines the “spirituality” as the individual’s belief in God or a higher

power that is concerned with his or her striving to achieve a sense of harmony with self

and others. Spirituality often involves a relationship with an organized religion,

interrelationships with others, and the search for the meaning of life. Affiliation and/or

6

participation in organized religion, however, are not necessary to be considered spiritual

(Burkhardt, 1989; Principe, 1983). Different authors have defined ‘spirituality’ in

various ways. For the purpose of this discussion, I will use the “spirituality” to describe

the way of life an individual chooses that involves a belief in God or a higher power, a

belief in an after life, and a belief that a higher power influences life’s events. I did not

limit this study to ‘spirituality’ associated with any specific religion or sect.

There has been an increasing interest in the interrelationship of spiritual

involvement, spiritual activity, and health outcomes among the elderly. Koenig,

McCullough, and Larson (2001) give three reasons for this current interest. First,

spirituality and religious affiliation continues to be a central part of people’s lives despite

advances in technology, education, and medicine. Second, the United States and other

worldwide populations are aging due to a declining birth rate and greater longevity. In

the future, social programs will have severe financial hardships in providing services for

this population and religious groups may assist in providing some of these services.

There is the possibility that spiritual coping may aid in the prevention of health problems

and thereby assist in health care cost containment. Finally, there is a depersonalization in

the health care delivery system. Individuals seeking medical care and treatment expect

compassion with attention to their social, psychological, and spiritual needs. McFadden

and Levin (1996) summarize recent gerontologic spiritual research as focusing on four

areas of interest: “(a) multidimensional measures, (b) patterns, (c) predictors, and (d)

psychosocial and health related outcomes of religious involvement in older adults and

across the life course” (p. 350).

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Summary

Many disciplines including medicine, psychology, and sociology have examined

the relationship of coping and religious affiliation; coping and spiritual beliefs; religious

attendance, and health outcomes like pain, depression, quality of life, mortality, and

morbidity. This investigator believes that the degree of spirituality in the post-surgical

older adult patient has not been considered in evaluating pain report and analgesic

medication use. Achieving adequate pain control is a major goal of professional nursing

care and utilizing spiritual coping may be an important addition in providing non-

pharmocologic pain management.

Specific Aims

The purpose of this study is to explore whether a high degree of spirituality, and

high scores for self-health assessment are correlated with postoperative pain and

analgesic medication use in the acute hospital recovery phase. Currently, there is no

evidence in literature that has examined these variables and their relationship with the use

of postoperative pain medication after total joint arthroplasty. Prior research focused on

relationships of long-term functional rehabilitation, quality of life and spiritual coping.

Using two multidimensional instruments, I propose to address three important aims that

will contribute to the relationship of spirituality, self-health assessment, pain report and

analgesic medication use in the postoperative older adult joint arthroplasty patient.

First, using a multidimensional instrument, this study will investigate whether a

high degree of spirituality is associated with less pain report and medication use in older

individuals receiving primary hip or knee arthroplasty for osteoarthritis. It is the aim of

this research to determine whether older adults receiving a hip or knee arthroplasty with a

8

high score for spirituality on the Spiritual Involvement and Beliefs Scale (SIBS) will use

less analgesic medication postoperatively.

Second, the Short Form-36 Health Survey that measures general health assessment

will be used to measure self-health in this research. It is the aim of this research to

determine whether older adults with a high score for health self-assessment will use less

analgesic medication after controlling for spirituality.

Finally, the responses for both spirituality and self-health together will be

correlated with analgesic medication.

Hypothesis 1. Older adults with a higher degree of spirituality receiving a hip or

knee arthroplasty for primary osteoarthritis will report less pain and receive less analgesic

medication than those participants with a lower degree of spirituality after controlling for

health self-assessment.

Hypothesis 2. Older adults with high scores on the self-health assessment tool will

report less pain and receive less analgesic medication than those participants with low

scores on the self-health assessment tool after controlling for spirituality.

Hypothesis 3. There will be significantly less analgesic medication used by those

older adults receiving hip or knee arthroplasty who have a high degree of spirituality, and

a high degree of self-health assessment.

Terminology

• Older adult: Age 55 or older

• Epidural: Medications administered to the epidural space surrounding the spinal cord.

• Extrinsic religious orientation: The pursuit of religious beliefs and religious practice to feel protected or gaining social status and approval.

9

• Femoral Nerve Sheath: Medication administered within the femoral nerve sheath by means of a catheter to anesthetize the femoral nerve.

• Intrinsic religious orientation: The motivation to live the goals set forth by religious tradition. The way of life often described as “living one’s religion” and using religious practices. The person who has an intrinsic religious orientation may not be affiliated with a particular religious group.

• Medication Administration Record (MARS): Individual record of medication administered to a patient during inpatient hospitalization. Each dose of medication is recorded with the following data: medication name, dosage, time administered, name of staff administering medication.

• Opioid equi-analgesic conversion: All narcotic medication was converted to Morphine Sulfate IV equivalents.

• Patient controlled analgesia: Self-administered narcotic analgesia through an intravenous infusion.

• Religious affiliation: Participating in an organized religious group

• Spirituality: The way of life an individual chooses to live that internalizes a belief in a higher power. These life thoughts are separate from the body and may involve God, a belief in an afterlife, and belief that this higher power influences life’s events.

• Spiritual behaviors: Praying, meditation and/or self-reflection, reading spiritual writings

• Visual Analog Scale (VAS): A pain rating scale adopted by Shands at the University of Florida to provide accuracy in a patient’s pain. The scale is numeric, one = no pain and

• 10 = the worst pain of life. Patients are asked to rate their pain using numeric increments 0 to 10.

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CHAPTER 2 REVIEW OF THE LITERATURE

This section deals with pertinent papers published during the past 20 years that

address chronic pain, osteoarthritis, lower extremity arthroplasty, and spirituality coping

among the elderly. The first section examines the prevalence of the chronic pain of

osteoarthritis and arthroplasty (focal stimuli), age, gender, and race (contextual stimuli).

The second reviews the relationship of spiritual coping to gender, race, age, and pain.

Presence of Musculoskeletal Chronic Pain and Arthritis Among Older Adults

Pain in the aged adult has become a focus of current gerontologic research. The

elderly have more painful diseases that require more medical visits. The impact of

musculoskeletal conditions on the elderly can be divided into two categories: 1) the

physical and social impact of physical pain (limitations in mobility and social interaction

imposed by these limitations), and 2) the monetary cost involved in the diagnosis and

treatment of these disorders (Praemer, Furner, & Rice, 1992). Musculoskeletal disorders

after age 65, regardless of gender or racial group, are the most frequently reported

physical impairments, exceeded only by hearing disorders. Surgical intervention,

following failed medical management, is expected to increase dramatically in the next

twenty years (Praemer, et al.1999). Musculoskeletal functional limitation has a

significant impact on the elderly.

Back and spine disorders are the most frequently reported category of dysfunction,

followed by lower extremity disorders of the hip or knee. Although there are many forms

of arthritis among the elderly, the two most common forms, those with the greatest public

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health implications, are osteoarthritis and rheumatoid arthritis. The more prevalent of the

two forms, osteoarthritis, is estimated to affect 20 million people in the United States

(Praemer, et al.1999).

The Relationship of Background Contextual Stimuli and Pain

Age, Pain, and Osteoarthritis

Anderson, et al. (1993) found that 90% of individuals surveyed experienced

chronic musculoskeletal pain. Chronic pain symptoms increased between ages 50-64 and

then gradually declined. After age 60, however, the incidence of lower extremity pain

increased. Compared to younger adults, lower joint pain doubled after age 65 (Anderson,

et al. 1993; Gibson & Helme, 1995). In the Iowa study, Mobily, et al. (1994) observed a

lower incidence of overall pain (p< .0001) among those over 85 years compared to

younger age groups. They also found more than 86% of those surveyed experienced pain

longer than 12 months. Their research is felt to be particularly accurate because of their

large sample size and the longitudinal study design.

Several studies have examined the influence of age on pain sensitivity. Gibson and

Helme ((1995) examined sensitivity to several different forms of experimental pain using

a meta-analysis. Their data suggest a decline in thermal sensitivity after age 60, but do

not show a conclusive difference, or change, in pain sensitivity or pain tolerance. An

earlier study by Helme and Allen (1992) had found that the majority of those surveyed

(79%) agreed that pain was a consequence of the aging process. However, less than half

of these older adults reported pain. The authors concluded that older adults expected to

experience pain as they aged and they did.

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Additional research is needed to evaluate both the physiologic and psychological

basis for pain among older adults. More effective management of pain in the older adult

originates in a better understanding of differences and similarities in the pain response.

Gender, Pain and Osteoarthritis

Experimental research has not demonstrated a conclusive difference in pain

perception related to gender. Using heat as a noxious stimulus in humans Paulson,

Minoshima, Morrow, and Casey (1998) concluded there was a gender similarity in the

cerebral and cerebellar activation, but anticipation of the stimulus was more intense in

females.

Keefe, et al. (2000) measured pain, disability, and pain behavior among men and

women with a mean age of 61.1 yrs. They reported significant gender differences in pain

intensity, pain behavior, and physical disability associated with osteoarthritis. Women

had significantly elevated levels (F (1,166)= 4.41, P <0.05) of osteoarthritis pain. They

measured pain behavior, which included stiff movement, rubbing affected joint, and

flexing the joint, in relation to gender. In their analysis women exhibited more pain

behavior than men (F (1,162) = 5.54, P < 0.05). In a recent study of pain and coping,

Affleck et al. (1999) observed that women reported daily osteoarthritis pain and pain

levels 73% greater than males with a similar arthritis diagnosis. Results of these studies

have suggested that among the elderly, there is a difference in pain intensity related to

gender. Further research is necessary to compare noxious pain stimuli, pain thresholds

and intensity studied in younger populations to the older adult.

Age, Gender, and Osteoarthritis

Compared to males, females have twice the incidence of osteoarthritis. Until age

65, however, men report a greater occurrence of osteoarthritis. While men are more

13

likely to have shoulder, elbow and foot joint pain; women have finger, hip, ankle and

wrist joint pain (Davis, Ettinger, Newhaus & Hauck, 1987). Although specific affected

joint patterns have been identified as following a gender pattern, gender differences do

not contribute to risk factors for the development of osteoarthritis (Davis, et al.

1987;Keefe, et al. 2000; Lawrence, et al. 1998).

Race, Pain and Osteoarthritis

Differences in cultural response to pain have been studied using two methods, non-

experimental using observational methods, and laboratory experimental using painful

stimuli and measuring the response. Zatzick and Dimsdale (1990) were unable to

correlate cultural variations in pain response in their meta-analysis of pain stimuli and of

pain response. They concluded, “there is no evidence suggesting that the

neurophysiology detection of pain varies across cultural boundaries” (p.554). However,

Bates, Edwards, and Anderson (1993) using observational methods to evaluate the

differences in reported chronic pain intensity among seven diverse ethnic groups, found

significant correlations. Additionally, they investigated specific sociodemographic,

medical, and psychological variables that may predict an intra-ethnic group variation in

pain intensity. Bates, et al. (1993) found that pain intensity did not vary among various

ethnic groups because of differences in neurophysiology but was a result of the

biocultural model of pain perception.

European whites have a greater incidence of osteoarthritis than Jamaicans, Blacks,

South African Blacks, Chinese, and Indians (Felson, 1988). Rates for American Indians

are intermediate. There is speculation that individuals of European white descent have a

genetic developmental defect in both the knee and hip joints that facilitates the

14

development of osteoarthritis. This is supported by greater reporting of joint pain in

whites when compared to blacks or other races (Praemer, et al. 1992).

Total Joint Arthroplasty

Prevalence

The first decade 21st century has been declared the “Bone and Joint Decade” by 35

nations and 44 U.S. states. The number of lower extremity joint procedures has

increased; total knee replacements increased 40.2% during the years 1990 and 1996,

while total hip replacements increased 15.5% for the same years (Praemer, et al. 1999).

Currently more than 425,000 total joint replacements are performed in the United States,

and this number is expected to reach 702,000 by the year 2030 as the baby boomer

generation ages (Praemer, et al. 1999).

The leading reason for joint replacement surgery in the elderly is failure of

conservative medical treatment for end stage arthritic joints. The increase in the number

of aging Americans, and the increase in prevalence of arthritis for this age group along

with a strong desire to remain active have continued to increase the demand for total joint

arthroplasty (Healy, Iorio, & Lemos, 2001). Joint replacement surgery has been shown to

improve pain, functional ability, social function, and quality of life (Aarons, et al. 1996;

McGuigan, et al. 1995; Norman-Taylor, et al. 1996; Ritter, et al. 1995).

The goal of total joint arthroplasty is to recreate the motion of flexion, extension,

adduction, and rotation of the joint that has lost range of motion. This surgical

intervention demonstrates a ten-year success rate for 98 % of elderly individuals while

relieving joint pain and correcting the joint deformity. For patients with bilateral knee

joint end stage arthritis, bilateral joint replacements are often performed at the same time

(Pellino, Preston, Bell, Newton, & Hansen, 2002).

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Total hip arthroplasty (THA) is a surgical procedure that replaces a diseased joint

with a synthetic joint using a synthetic acetabulum, femur, and polyethylene liner that are

fixed to bone by cement or bone ingrowths. Total knee arthroplasty (TKA) involves

replacing the femoral and tibia sides of the joint using a long or short stem fixated by

cement. The goal of joint arthroplasty is to improve function with an artificial joint that

improves range of motion and provides pain relief with few surgical complications

(Brander, Mullarkey, & Stulberg, 2001). The decision making process in considering a

candidate for total joint replacement is the degree of radiographic changes and the degree

of functional impairment.

Gender and Arthroplasty

Although women have 1.5-2.0 higher incidence of osteoarthritis, men have more

total knee arthroplasty than women. Katz, et al. (1994) suggests that gender differences

in joint arthroplasty are difficult to evaluate because procedure rates are not reported by

severity of disease. The authors evaluated functional status using a daily living scale that

evaluates the ability to walk several blocks, climb stairs, or take part in vigorous activity.

Greater functional impairment and the use of walking support were reported for most of

the females. The authors suggest that males have earlier surgical intervention for

functional impairment and pain. Praemer, et al. (1999) do report that the number of total

knee replacements for men in 1996 was 1318/100,000 while for women in the same year

it was 928/ 100,000. There is some evidence that suggests women delay surgical

intervention out of fear of surgical failure, death or loss of function postoperatively.

Postponing surgical intervention can also be because of distrust of physicians and

hospitals, a reluctance to take risks and concern about caregiving responsibilities.

16

Conversely, males most reported concern is the length of rehabilitation time necessary for

the return of joint function (Ritter, et al. 1995).

Race and Arthroplasty

The relationship between race and arthroplasty has been poorly studied. A recent

study in a large county in Texas reported that Hispanics were under represented as

recipients for hip replacement surgery (Escalante, Espinosa-Morales, Del Rincon,

Arroyo, & Older, 2000). In their research, African Americans were also less likely than

Caucasians to receive arthroplasty surgery. Extensive review of research literature on

race and arthroplasty, however, revealed no evidence to suggest a disparity in race and

arthroplasty.

In summary, the number of total joint replacements increases dramatically for both

sexes after age 65 (Praemer, et al. 1999). The effect of this increase can be directly

attributed to the incidence of joint osteoarthritis, chronic pain and functional impairment

(Felson, 1988; Schlesinger, 2001). Women report greater functional impairment for all

activities of daily living and delay arthroplasty for a longer period of time. It is unclear

from previous research reasons for gender differences in osteoarthritis incidence or the

delay for surgical intervention. Previous research only verifies the age related changes of

osteoarthritis, functional impairment and the increase in total joint replacement surgery

for the relief of pain and improvement in physical function.

Spiritual Coping

According to Lazarus, DeLongis, Folkman, and Gruen, (1985), “efficacy

expectations and appraisals refer to cognitions: fear and distress refer to emotional states

that includes cognitions” (p. 776). Stress is regarded as a complex variable and the

individual in his/her personal environment reflects the processing of these variables.

17

Good health and the absence of chronic pain represent a person’s stable environment. An

individual’s inability to maintain these environmental variables creates stress and fear.

Through evaluating the stressors and using defense strategies, a coping process will be

used to overcome the disruption in a person’s environment (Lazarus et al, 1985). The

older adult uses cognitive interpretation to identify stressful health changes and uses more

defense strategies to cope. Diehl, Coyle, and Labouvie-Vief, (1996) found that compared

to younger people; there was a difference in the use of self-restraint by older adults rather

than aggression to cope with environmental stressors.

Religious behaviors such as prayer, religious service attendance and seeking

spiritual connection, are part of the individual’s practice of spiritual or religious coping

(Ellison & Levin, 1998; Koenig & Larson, 1998; Pargament, et al. 1998). Researchers

have studied the various spirituality concepts: 1) Religious doctrine; 2) Religious

attendance; and 3) Religious affiliation.

Spirituality includes both the world of experience and the way of life a person lives

that is guided by religious doctrine (Principe, 1983). It is the continuous process of

integrating oneself in current and past experience and the effort of relating to others with

trust and understanding. Spirituality links self with a power greater than the individual.

It is most often associated with a religion that defines the divine and offers ways to relate

to the sacred (McFadden & Gerl, 1990). Fowler describes the persons life spiritual

development as a developmental psychological process that uses cognitive and emotional

synthesis of a sense of meaning and purpose in the life journey (Shulik, 1988).

Interest in research involving the relationship of spirituality and health has been

increasing over the past 15 years. Most existing research has focused on religious

18

affiliation and health status in hypertension, depression, mortality, and anxiety (Clark,

Friedman, Martin, 1999; Husaini, Blasi & Miller, 1999; Koenig, et al. 1993, 1994). The

examination of a possible therapeutic effect of spirituality in the postoperative joint

replacement patient has not been explored. Levin and Chatters (1998) suggest that in

order to establish a relationship between spirituality and health, research must use

evaluate a measurable medical effect of spirituality or religion and aging. This research

will hypothesize that a positive relationship does exist between the older adult’s degree of

spirituality and self-health assessment.

Spiritual Coping and Health

There has been no published research demonstrating a relationship between

spiritual coping, health assessment, and post-surgical pain. Most empirical research has

focused on the relationships of spiritual coping, spiritual beliefs, spiritual involvement

and health outcomes in mental health, hypertension, depression, and anxiety. Matthews,

et al. (1998) reviewed the relationships of religious factors that included religious

attendance and mental health status. The focal areas of mental health status were coping

and recovery from illness. The authors concluded in their review there was strong

support for religious commitment and positive medical outcomes following serious

illnesses e.g. heart disease, cancer. Pargament, et al. (1998) using a spiritual well being

scale found there was a relationship between positive and negative patterns of religious

coping in young and elderly age groups. They measured three diverse sample groups

experiencing stressful life events. The first sample represented Oklahoma City residents

who were evaluated for religious coping after the federal building bombing. The second

sample involved college students who had experienced a significant negative event, such

as a death of a friend or family problems. The third sample group was hospitalized

19

patients over the age of 55 with moderately severe medical illness. Although, the

participants were of different ages and diverse life event stressors, a positive pattern of

religious coping was found among the three groups. Those participants with positive

religious coping patterns had less psychological anxiety and distress. Those individuals

with negative religious coping were associated with greater emotional distress, e.g.

depression, and reported poorer quality of life. Pargament and colleagues (1990),

extended their religious coping research to more clearly identify the kinds of religious

beliefs, and behaviors that are helpful to individuals as they cope with negative life

events like death, illness, divorce and work related problems. Four separate themes of

religious beliefs and behaviors emerged to further define spiritual beliefs and practice: 1)

belief in a fair and loving God; 2) partnership with God is supportive; 3) positive

outcomes come from using of religious rituals; and 4) search for spiritual and personal

support through religious affiliation. Pargament, et al. (1990) explains nonreligious

avoidance with descriptor items from personal narratives such as “tried not to think about

it,” “wished the situation would go away” (p. 818).

Using retrospective demographic data collection, early research that focused on

religious affiliation and health status demonstrated positive relationships between

religious affiliation and various health correlates, such as hypertension control,

depression, anxiety, length of hospital stay and mortality (Koenig, et al. 1993; 1998;

Koenig & Larson, 1998; Meador, et al. 1992). In a review of 20 empirical studies, Levin

& Vanderpool (1990) concluded that religion is therapeutically beneficial in the control

of hypertension. Koenig, et al. (1998) investigated the relationship of religious activities

and blood pressure control among older adults dwelling in communities. They concluded

20

that religiously active adults displayed lower blood pressures and were more compliant

with prescribed medication. Additionally, they observed a racial difference. The authors

found that although black religious males had higher blood pressures than white religious

males, they were more compliant with medication use for blood pressure control.

Recent research has examined spirituality and functional ability during

rehabilitation. Kim, Heinemann, Bode, Sliwa, & King (2000) examined spirituality using

an intrinsic Judeo-Christian scale of well-being and functional variables among patients

in a rehabilitation hospital. Intrinsic religiousness is defined as the individual’s

internalizing a religious belief and living the belief. Individual spirituality scores though

high were not associated with variables of functional recovery such as mobility, and self-

care. Fitchett, Rybarcyk, DeMarco, and Nicholas (1999) found similar results in

postoperative rehabilitation. There was a high degree of spirituality among their patients

who rated their health as poor or very poor. Using a questionnaire that measures church

affiliation, attendance, and spiritual behaviors, the authors were unable to confirm a

relationship between self-health assessment, spirituality, and church activities. Pressman,

Lyons, Larson, and Strain (1990) in a small study of postoperative female orthopedic

patients found significant correlation between church attendance, personal importance of

religion, degree of spirituality, and functional meters walked (r=0.45, df = 27, p<0.05).

This research found that postoperative orthopedic subjects with strong religious beliefs

and practices, and less depression had better ambulatory function at discharge. The

spirituality score was not significantly correlated with ambulatory status independent of

depression. The authors suggest that subjects who are spiritual respond more favorably

to physical therapy because they are less depressed. Hodges, Humphreys, and Eck

21

(2002) investigated the effects of spirituality on spinal surgery recovery. Using a

spirituality tool that evaluates intrinsic spirituality, they found these subjects to be highly

spiritual (79%). The authors then compared preoperative and postoperative pain scores

with postoperative functional ability. They found no correlation between a high degree

of spirituality and pain scores or functional outcomes.

Spiritual research has investigated the possible relationships of pain, health and

functional recovery. In each study, older adults have a high degree of spirituality on

various measurement tools, but only one study reported a significant correlation that

included a finding of less depression. The investigation of spirituality and health has not

been evaluated using consistent measures of spirituality scales and postoperative

population groups. Most current research has observed possible religious affiliation,

spiritual beliefs and functional status.

Relationships between Spiritual Beliefs, Gender and Race

Few empirical studies have examined pain, gender, and racial relationships

(Affleck, et al.1999). Research regarding utilization of health services demonstrated a

positive correlation between utilization and religious attendance in elderly male patients

60+ years of age. Increased attendance at religious services prior to hospitalization

correlated with a shorter hospital stay and fewer hospital admissions (Koenig & Larson,

1998).

Past research concentrated on religious coping behaviors, including religious

affiliation, beliefs and involvement. Research findings suggest that many older adults use

spiritual coping in various stressful health situations and that this coping has had a

beneficial effect. Further investigation is needed using spiritual measures to examine if

22

there is a spiritual coping adaptive effect in the management of older adult postoperative

pain.

Roy Adaptation Model-Based Research

In 1976, Sister Callista Roy’s theory of an adaptation model for nursing was

presented to guide nursing education in the United States. The theory was later revised to

address the middle range or practice level theory relevant to patient care in nursing. In

1999, a new model of the Human Adaptive system was introduced to clarify the

understanding of the various components of the theory and to extend it into clinical

practice (Roy & Andrews, 1999). Roy defines the purpose of nursing practice as the

promotion of the ability of human adaptive systems to adjust effectively to changes in the

environment and to the individual’s ability to modify their environment (Roy &

Andrews, 1999). Roy’s theory contains scientific and philosophical assumptions that

describe successful human coping in changing environments. According to Roy, the

adaptation of the human system is based on scientific assumptions that include: 1)

meaning is necessary for person and environment integration; 2) thinking and feeling is

necessary for awareness; 3) people have a commonality of patterns and relationships; 4)

adaptation results from the integration people and their environment. Further, the

adaptation concept includes Roy’s philosophical assumptions: 1) relationships include a

higher power and the world; 2) people use the ability of faith; 3) God is observed in

diversity of creation, and is the destiny of creation.

23

Figure 2-1. Model Diagram of Research Questions

Roy Adaptation Model Gerontologic Research

Roy describes the adaptive process as adjusting effectively to environmental

changes using cognitive interpretation and coping processes to maintain an integrated

life. In this model, compensatory life processes are spiritual coping and health self-

assessment. These regulatory processes provide an adaptive response for less pain.

Roy’s adaptation model has been used mainly with children and adults in a hospital

environment. One gerontologic study has used the Roy adaptation model to evaluate a

coping process and the concept of self-consistency. Roy believes the concept of personal

self is a combination of self-consistency, the moral-ethical spiritual self and the self-ideal

(Roy & Andrews, 1999). Zhan (2000) used the Roy Adaptation Model to study

adaptation and coping with severe hearing loss in 130 elderly adults. Health status and

coping data were analyzed for positive relationships between cognitive coping and self-

24

consistency. There was a positive correlation between those who rated their health as

good or excellent and self-consistency. The variance in self-consistency was the result of

cognitive coping processes. Three cognitive processes; clear focus and method, knowing

awareness, and self-perception were most significant (36.97 (p< .001, df =5).

There is support for the use of the Roy Adaptation Model in gerontological

research to evaluate spiritual coping and adaptation to pain. Successful adaptation to

environmental changes is necessary to return to good health and well being as people age.

Summary

Chronic pain in the aged adult is both a physical and emotional experience.

Current research suggests that the use of pharmocologic and non-pharmocologic methods

in the elderly may reduce chronic pain. However, some research findings suggest that the

use of specific non-pharmocologic interventions such as spiritual behavior, religious

attendance, and spiritual beliefs are inconclusive in providing relief from the negative

effects of chronic illness and pain. This research study will evaluate relationships

between spirituality and analgesic medication use after total joint arthroplasty in older

adults.

Measurement of the degree of spirituality and health will evaluate the effectiveness

of coping with postoperative pain in the older adult. This research will provide

quantitative data to provide a framework for evaluating older adult’s spirituality as an

alternative non-pharmocologic intervention in postoperative pain management.

25

CHAPTER 3 METHODS

Research Design

This research examines the relationship of older adults’ spiritual beliefs, and self-

health assessment and analgesic medication use during the first three days after total joint

replacement surgery. A correlational convenience design was used to investigate the

questions in a sample of surgical candidates scheduled for hip and knee joint arthroplasty.

Using the Roy Adaptation Model, this study examined relationships between total joint

arthroplasty for osteoarthritis, chronic pain, the degree of spiritual beliefs, spiritual

involvement, self-health assessment and the health outcome of postoperative analgesic

medication use. Participants for this research came from a socially diverse area in North

Florida.

Controls

Three orthopedic surgeons from the University of Florida College of Medicine,

Department of Orthopedics performed all of the total joint arthroplasty. To control

variations in general anesthesia technique, one supervising anesthesiologist planned each

participant’s anesthetic care. Participants chose his/her preferred method of

postoperative pain control prior to surgery. Choices included regional anesthesia, Patient

Control Analgesia (PCA), or PRN dosing. Preoperative patient education and anesthesia

evaluation was done according to the standard of care established by the University of

Florida College of Medicine.

26

Inclusion criteria:

1. 55 years of age or older

2. Primary hip or knee joint arthroplasty

3. Osteoarthritis of the hip or knee joint as demonstrated by radiographic exam and orthopedic surgeon’s diagnosis as documented in the medical record

4. Failed medical management of chronic joint pain

5. Inclusion regardless of comorbidity status

6. Candidates for hip or knee arthroplasty

Power Analysis and Sample Size

An estimate of statistical power was determined using the G power computer

software to calculate the required sample size. A total of 115 participants were consented

and completed the study. The sample size was based on a formulation of 80% power, at

least six independent variables, an effect size of 0.15 (R-squared= 0.13) with a

significance of 0.05 for a two-tailed test. The G power computer software was used to

calculate the required sample size (Erdfelder, Faul, & Buchner, 1996).

Procedures

The Principle investigator of this study contacted the chairman of the Orthopedic

Department and presented a description of the study. The chairman then provided a

signed letter of agreement acknowledging awareness of this study (See Appendix A).

In the original protocol, I planned control variation in surgical technique using only

patients scheduled with one orthopedic surgeon. A total of 27 patients were enrolled

from July, 2003 until January, 2004. During this enrollment period, however, the

identified surgeon reduced the number of total joint surgeries he performed per month in

order to fulfill administrative duties. In January, 2004, the investigator met with

committee members to explore adding two additional surgeons in order to attain within a

27

reasonable length of time a number of subjects months adequate for a power analysis.

After appropriated discussions, two additional orthopedic surgeons agreed to help. They

were each provided a copy of the protocol and informed consent. A revision that

included the two additional orthopedic surgeons was submitted and approved by the IRB

in January, 2004.

Protection of Human Subjects

University of Florida Institutional Review Board (IRB) approval was obtained prior

to participant enrollment or data collection (See Appendix B for final approval, revised

approval and extension approval forms). A revision to include the additional orthopedic

surgeons was submitted and approved in January, 2004. A final IRB extension was

submitted June, 2004 to extend the research study from July, 2004 until July, 2005.

Method

Patients scheduled for surgery are scheduled in the pre-surgical center for an

examination by an ARNP to determine their suitability for anesthesia. From this group

the principal investigator identified potential subjects for study. Subjects who met the

inclusion criteria and agreed to participate in the study were given a verbal description of

the study, confidentiality assurance, and possible risks of their participation. Those

patients who expressed willingness to participate completed two questionnaires. The

questionnaires took approximately 20 minutes to complete during their pre-operative

visit. The principal investigator and each subject signed a copy of the informed consent.

A copy of the signed informed consent was given to the participant for their individual

records. The principal investigator verbally asked each subject if they had additional

questions regarding their participation in this research study prior to their discharge from

the pre-surgical center.

28

A key containing the participant’s name, and confidential code was developed.

Informed consents and questionnaires were coded with the participant’s confidential code

and are kept in a locked file cabinet in the principal investigator’s office.

Measures

Demographic data. Age, gender and ethnicity were coded using a coding key

(see Appendix G). Demographic data was entered on an Excel spreadsheet after

enrollment. There was no missing demographic data.

Preoperative Questionnaire Measures

Indicator of spirituality

The Spiritual Involvement and Belief Scale- (Revised (SIBS-R) Hatch, Burg,

Naberhaus, & Hellmich (1998) evaluates a broad range of intrinsic spiritual content from

ability to find meaning in life to spiritual writings. Designed for use with individuals of

all religious and non-religious traditions that include Christian, Judeo, Hindu, Islam and

Atheist. This instrument differs from other spiritual measurement tools in that it is not

limited to individuals with a Judeo-Christian tradition.

For the purpose of this study one question was selected to evaluate participants’

spirituality. Two groups were created using the response to the question, “How spiritual

a person do you consider yourself?” Subjects were asked to rate themselves on a scale of

1 to 7 with 7 meaning “the most spiritual”. Those groups who rated themselves 5, 6, or 7

were considered highly spiritual and coded as 1. Those who rated their spirituality as

1,2,3, or 4 were considered less spiritual and coded as 0

Indicator of self-health assessment

The Rand SF-36 Health Status Questionnaire measures physical functioning, social

functioning, role functioning (physical problems) and role functioning (emotional

29

problems). Additionally, the instrument measures mental health, fatigue, pain, and

general health.

One question, “In general would you say your health is”, was used to create two

groups for the analysis. If a participant answered good, very good or excellent, their

response was considered as a high self-health assessment and coded as 1. If their

response was fair or poor, their self-health assessment was considered a low score and

coded as 0

Questionnaire data. Using the patient’s confidential code all questionnaire data

was entered using an excel spreadsheet. Missing data on questionnaires was entered as a

dot.

Indicator of diagnosed osteoarthritis. A diagnosis of osteoarthritis was recorded by

the orthopedic surgeon and is available in each individual participant’s medical record.

The diagnosis was verified with the individual’s pre-surgical history and physical

assessment.

Indicator of ethnicity

Ethnicity was obtained from the patient’s admission record. The admissions

department routinely obtains ethnicity information during a patient’s initial interview

prior to entering the hospital.

Postoperative Data Collection Procedures

Indicator of pain scores. Individual postoperative pain scores were obtained from

the individual’s medical record. Daily pain scores were recorded and averaged for three

days postoperatively. Additionally, a daily median pain score was recorded for this same

interval. Pain was evaluated using the Visual Analog Scale (VAS) that evaluates pain

intensity numerically using a 0 to 10 measurement (0= no pain, 10= worst pain). The

30

VAS instrument is used with all age groups and is the approved pain scale for use at

Shands Hospital at the University of Florida.

Analgesic medication use. Medications dispensed during a patient’s hospitalization

are records in the Medication Administration Record (MARS). The MARS documents

each dose of medicine administered by nursing personnel. This medication record

contains the medication name, date, time, dosage and initials of hospital personnel

administering the medication. Individual Medication Administration Records (MARS)

were evaluated for the use of narcotic analgesic medication for every participant. . An

Opioid equi-analgesic conversion table was used and all opiates were standardized to

morphine sulfate equivalents. For example, 1.5 mg IV Hydromorphone = 100 mcg

IV/SC Fentanyl = 20 mg P.O. Oxycodone = 10 mg IV Morphine (Pasero, Portenoy &

McCaffery, 1999). Total IV Morphine Sulfate equi-analgesic conversion was recorded

for each postoperative day for three days.

Regional anesthesia use. Regional anesthesia techniques such as epidural, Femoral

Nerve Sheath Catheters, and Psoais Compartment Catheters provide postoperative pain

relief by blocking nerve conduction with local anesthetics, thereby blocking the

transmission of pain (Pasero, Portenoy, & McCaffery, 1999). The use of a local

anesthestic provides a sensory and motor blockage. The epidural regional anesthesia

technique occasionally requires the use of an opioid agent in addition to a blocking agent.

The use of an opioid agent is recorded on a separate analgesic document in the patient’s

medical record. The placement location of regional anesthesia is recorded on a separate

document located within the patient’s medical record.

31

Medical record data. Medical record data collected included surgical site,

anesthesia data, pain scores and analgesic medication used. A form was developed (see

appendix) to collect data from the participant’s medical record after discharge. Medical

records were requested using a Request for Records review and Shands at the UF

Research Chart Request forms. An average of 4-20 charts were requested each time;

medical records usually required two weeks to be assembled. Several delays were

experienced in obtaining medical records that included research medical records

personnel vacation days, sick days, and incomplete delivery of records. One medical

record has been lost. Two records are incomplete with medication records missing.

The Medical Record Department requires that all data and chart review must be

preformed in the records department. Using the coding key, data was recorded on the

case coding form. Pain scores were documented as average scores and median pain

scores. All opioid medications were converted to Morphine Sulfate IV equi-analgesics

and recorded. Surgical site, anesthesia type, regional anesthesia, general anesthesia were

coded using the coding key.

Data Analysis

Data obtained in the postoperative period were entered on an Excel spreadsheet.

Analysis used SPSS statistical software, Version 11 for Windows. Demographic data for

spirituality, self-health assessment, age, gender, pain scores, and analgesic medication

use were analyzed to generate descriptive statistics using mean scores and frequencies

The hypotheses were tested with analysis procedures using Pearson’s correlation

coefficient, T-Test and ANOVA with significance levels of 0.05. Correlations measure

how variables are related and measure their linear association. Frequencies and mean

scores were analyzed for all demographic data, age, gender, operative site, physician,

32

regional anesthesia and analgesic medication use. Individual survey questionnaire items

were analyzed using frequency and percentage of individual participant response.

Summary

This chapter presented research design, sample inclusion, power analysis,

methodology, and data collection procedures for this study. Data analysis methodology

for research hypotheses was discussed.

33

CHAPTER 4 RESULTS

A description of the participants and the results of this descriptive study are

presented in this chapter. The results are examined in relation to the three hypotheses.

This study took place at Shands at the University of Florida. Subjects were recruited as a

convenience sample that included only persons that met the inclusion criteria. Informed

Consent and questionnaire data were collected in the pre-surgical anesthesia clinic.

Demographic data, pain scores and medication use were obtained from the subject’s

medical record after hospital discharge. All data was computed using the SPSS statistical

software, version 11 for Windows. Statistical significance was set at p < 0.05.

Sample Characteristics

A total of 126 potential subjects who met the inclusion criteria were approached to

participate in the study. Eleven potential participants declined to participate. Three

stated they were “tired of filling out paperwork”, two did not want to participate in any

research and one did not believe in spirituality. Five did not express a reason for refusing

participation. None of the potential research participants expressed any fear of an

adverse event by participating in this study. All subjects who agreed to participate signed

an informed consent and completed the two questionnaires in the pre-operative anesthesia

center. At the end of the study one subject’s medical record was missing from the

Medical Records Department and after a detailed search was considered lost. One

subject’s Medication Administration Record was missing from the medical record and

34

presumed lost. All other participants’ medical records were complete at the end of the

data collection period.

One hundred and fifteen subjects who met the inclusion criteria were consented.

The mean age of the sample was 67.70 (SD = 8.23). Seventy- four (64.3 %) of the

participants were female and 41 (35.7%) were males. The majority of the participants

were Caucasian (n = 111), followed by Hispanic (n = 2) and African American (n = 1).

All participants were diagnosed with severe osteoarthritis and had failed

conservative medical management. Right total knee arthroplasty was the joint

replacement most frequently performed at 35% (n = 35), followed by left total knee

arthroplasty at 27.8% (n = 32), right total hip arthroplasty 18% (n=18), left total hip

arthroplasty at 13.9% (n =16), and bilateral total knee arthroplasty at 10.4% (n = 12).

Regional Anesthesia

Forty-six percent (n = 56) of the participants chose a femoral nerve sheath for post-

operative pain control, while 25.2% (n = 29) chose an epidural, 3.5% (n = 4) chose a

psoas compartment sheath, and 1.7% chose a continuous spinal. Patient controlled

analgesia (PCA) was used by 67% (n = 77) of subjects. The PCA group includes some of

the subjects who received a femoral nerve sheath. All other participants selected “as

needed” analgesia for postoperative pain control.

Anesthesia Technique During Surgery

General anesthesia was administered to 100 participants (87%) followed by

continuous spinal at 4.3% (n = 5), followed by managed anesthesia care at 2.6% (n=3).

35

Analysis of Data in Relation to the Hypotheses

Hypothesis 1

Hypothesis 1 stated that older adults with a high degree of spirituality receiving hip

or knee arthroplasty for primary osteoarthritis would report less pain and receive less

analgesic medication than those participants with a lower degree of spirituality after

controlling for health self-assessment.

The Pearson Correlational analysis as shown in Table 3, demonstrated there was no

significant correlation between spirituality response, self-health questionnaire response

and the following variables: age (r = -0.02, p = 0.84), average pain scores day one (r=

0.01, p = 0.92), average pain scores day two (r = 0.02, p = 0.84), average pain scores day

three (r = 0.03, p = 0.78) and analgesic medication use (r = -0.04, p = 0.69). A partial

correlation coefficient controlling for the self-health assessment score was then analyzed

(See Table 4) and there were no significant correlations between spirituality, and the

variables: age (r = -0.05, p = 0.60), pain day one (r = 0.53, p = 0.59), pain day two (r =

0.06, p = 0.53), pain day three (r = 0.06, p = 0.56) and pain medication (r = -0.02, p =

0.81). Hence, Hypothesis 1 was rejected.

Hypothesis 2

Hypothesis 2 stated that older adults with a high score on the high self-health

assessment tool would report less pain and receive less analgesic medication than those

participants with a low score on the self-health assessment tool after controlling for

spirituality.

The Pearson Correlation found there was a significant correlation as shown in

Table 5 between the variable for health on the Short Form-36 Health Survey and age (r =

0.23, p = 0.02), average pain scores day one (r = -0.31, p = 0.00), day two (r= -0.29, p =

36

0.00) and day three (r = -0.22, p = 0.03). There were similar results for days one, two,

and three and median pain scores. However, there was no significant correlation between

the variables, analgesic medication use (r = -0.11, p = 0.23) or high spirituality (r = 0.13,

p = 0.17) as shown in Table 5.

A Pearson Partial correlation for health assessment while controlling for spirituality

was analyzed. There was a statistically significant correlation for the following variables:

age (r = 0.23, p = 0.02), pain scores on day one (r = -0.31, p = 0.00), day two (r = - 0.29,

p = 0.00), day three (r = -0.22, p = 0.02). There was no significance for less analgesic

medication use (r = -0.11, p = 0.26) as shown in Table 6. The results confirmed

Hypothesis 2 for pain, but rejected it for analgesic medication use.

Hypothesis 3

Hypothesis 3 stated that there would be less analgesic medication used in those

older adults receiving hip or knee arthroplasty who had a high degree of spirituality

involvement and beliefs and a high score on the self-health assessment tool.

An ANOVA regression was used to determine if there was an interaction between

good to excellent health and a high degree of spirituality. The relationship was not

significant (F = 1.04, p = 0.38). Further analysis a T-Test was used to determine if there

was a difference in the average analgesic medication use between the high spirituality

group and the good to excellent self-assessed health group (Ms = 7.63 and 8.49

respectively). Hypothesis 3 was rejected.

Additional Findings

For the purpose of this research, one question rating degree of spirituality was used

from this scale. The SIBS tool was satisfactory and demonstrated a Cronbach Coefficient

Alpha 0.94 Raw Score. Each participant completed the 39-item questionnaire and there

37

were a many positive responses to specific questions on the spirituality and beliefs scale.

For example, on the item “spiritual health contributes to physical health,” 70.4% agreed

or strongly agreed. Most participants considered themselves spiritual when asked to rate

their spirituality on a scale of 1 to 7 (with “7” being the most spiritual). Participants used

religious coping such as hope, personal relationship with a greater power than self, and a

belief that prayer changes things. A high number of participants (77%) wanted others to

pray for them during their illness. More than 70% of the respondents felt that spiritual

health contributes to physical health. Additionally, 95 or 82.6% of the participants

always or almost always make an effort to apologize when they do wrong to someone.

Overall scores on the SIBS instrument reflected a positive relationship with a higher

power, prayer, a belief in an after life, and continued spiritual growth (see Table 7).

Participants expressed difficulty with the SIBS questionnaire and often said, “this is

too hard to answer” or, “ I have to think a lot”. However, no participant asked for

clarification of a SIBS question.

The Short Form-36 Health Survey

For the purposes of this research participant response to the question “In general

would you say your health is: excellent, very good, good, fair, poor” was used for

analysis. Participants answered the 11-item self-assessment tool that queried physical

and emotional function. It is of interest that most were “limited a lot” for vigorous and

moderate activities. Daily activities such as walking, bending, kneeling and stooping had

the highest response for “limited a lot”. Simple activities such as dressing and bathing

were least limited. The tool seemed easier than the SIBS for participants to complete and

there were no missed questions.

38

Table 1. Frequency and Percent of Variables Variable Frequency Percentage Sex

Male 41 35.7 Female 74 64.3

Ethnicity

White 111 96.5 African American 1 .9 Hispanic 2 1.8

Operative Site

No response 2 1.7 Left Total Hip Arthroplasty 16 13.9 Right Total Hip Arthroplasty 18 15.7 Left Total Knee Arthroplasty 32 27.8 Right Total Knee Arthroplasty 35 30.4 Bilateral Total Knee Arthroplasty 12 10.4

Orthopedic Surgeon

Surgeon #1 81 70.4 Surgeon #2 23 20.0 Surgeon #3 11 9.6

Regional Anesthesia

No Regional 22 19.1 No Response 1 .9 Epidural 29 25.2 Femoral Nerve Sheath 56 48.7 Psoas Compartment Sheath 4 3.5 Continuous Spinal 2 1.7 Spinal 1 .9

Patient Controlled Analgesia

No Response 3 2.6 No PCA 35 30.4 PCA 77 67.0

Anesthesia Type

No Response 2 1.7 GETA 100 87.0 Spinal 5 4.3 MAC 3 2.6 Continuous Spinal 5 4.3

39

Table 2. Summary Measures of Variables Variable N Mean Std. Dev Minimum Maximum Age 115 67.70 8.23 55.00 86.00 Av. Pain

Scores day 1 113 3.34 1.99 0 9.13

Av. Pain

Scores day 2 111 2.28 2.04 0 7.20

Av Pain Scores day 3

106 2.24 2.15 0 9.20

Median Pain Scores day 1

113 2.97 2.67 0 9.75

Median Pain

Scores day 2 111 2.01 2.31 0 9.00

Median Pain Scores day 3

105 2.11 2.38 0 9.00

Health Self- 115 0.82 0.39 0 1.00 Assessment Spirituality 111 0.69 0.46 0 1.00 Table 3. Pearson Correlation Coefficients-Spirituality and Variables with No

Adjustments Variables r value p value n Age -0.02 0.84 111 Pain Day 1 (average) 0.01 0.92 109 Pain Day 2 (average) 0.02 0.84 108 Pain Day 3 (average) 0.03 0.78 103 Pain Day 1 (median) 0.01 0.91 109 Pain Day 2 (median) -0.03 0.75 108 Pain Day 3 (median) 0.10 0.30 102 Analgesic Medication Use Day 1-3 -0.04 0.69 109 Table 4. Pearson Partial Coefficients-Controlling for Health Assessment Variables r value p value n Age -0.05 0.60 108 Pain Day 1 (average) 0.05 0.59 106 Pain Day 2 (average) 0.06 0.53 105 Pain Day 3 (average) 0.06 0.56 100 Pain Day 1 (median) 0.05 0.63 106 Pain Day 2 (median) 0.01 0.92 105 Pain Day 3 (median) 0.13 0.18 99 Analgesic Medication Use Day 1-3 -0.02 0.81 106

40

Table 5. Pearson Correlation Coefficients-Health Self-Assessment and Variables with No Adjustments

Variables r value p value n Age 0.23 0.02 115 Pain Day 1 (average) -0.31 0.00 113 Pain Day 2 (average) -0.29 0.00 111 Pain Day 3 (average) -0.22 0.03 106 Pain Day 1 (median) -0.26 0.01 113 Pain Day 2 (median) -0.30 0.00 111 Pain Day 3 (median) -0.21 0.04 105 Analgesic Medication Use Day 1-3 -0.11 0.23 113 Spirituality 0.13 0.17 111 Table 6. Pearson Partial Coefficients-Health Self-Assessment and Variables Controlling

for Spirituality Variables r value p value n Age 0.23 0.02 108 Pain Day 1 (average) -0.31 0.00 106 Pain Day 2 (average) -0.29 0.00 105 Pain Day 3 (average) -0.22 0.02 100 Pain Day 1 (median) -0.26 0.01 106 Pain Day 2 (median) -0.30 0.00 105 Pain Day 3 (median) -0.22 0.03 99 Analgesic Medication Use Day 1-3 -0.11 0.26 106

41

Table 7. Frequencies and Percentages for Self- Reported SIBS Questionnaire (N=115). Answers reflect Agree or Strongly Agree scores only except for questions that are reverse score negatively worded items. These items were scored disagree or strongly agree.

Frequency Percentage

(1) I set aside time for meditation and/or self-reflection.

51 44.3

(2) I can find meaning in times of hardship. 67 58.3

(3) A person can be fulfilled without pursuing active spiritual life. (disagree/strongly disagree)

43 37.4

(4) I find serenity by accepting things as they are. 53 45.0

(5) Some experiences can be understood only through one’s spiritual beliefs

64 55.6

(6) I do not believe in an afterlife. (disagree/strongly disagree)

70 60.9

(7) A spiritual force influences the events in my life. 70 60.9

(8) I have a relationship with someone I can turn to for spiritual guidance.

69 60

(9) Prayers do not really change what happens. (disagree/strongly disagree)

79 68.7

(10) Participating in spiritual activities helps me forgive other people.

70 60.9

(11) I find inner peace when I am in harmony with nature.

68 59.2

(12) Everything happens for a greater purpose 70 60.9

(13) I use contemplation to get in touch with my true self.

43 37.4

(14) My spiritual life fulfills me in ways that material possessions do not. (This question is missed by 25 or 21.7% do to its position in the questionnaire)

62 53.9

(15) I rarely feel connected to something greater than myself. (disagree/strongly disagree)

62 53.9

(16) In times of despair, I can find little reason to hope. (disagree/strongly disagree)

80 69.6

(17) When I am sick, I would like others to pray for me.

89 77.4

42

Table 7. Continued Answers reflect Agree or Strongly Agree scores only except for questions that are reverse score negatively worded items. These items were scored disagree or strongly agree.

Frequency Percentage

(18) I have a personal relationship with a power greater than myself

81 70.4

(19) I have had a spiritual experience that greatly changed my life

57 49.6

(20) When I help others, I expect nothing in return. 98 84.2

(21) I don’t take time to appreciate nature. (disagree/strongly disagree)

70 60.9

(22) I depend on a higher power. 70 60.9

(23) I have joy in my life because of my spirituality 74 64.3

(24) My relationship with a higher power helps me love others more completely.

69 60.0

(25) Spiritual writings enrich my life. 61 52.1

(26) I have experienced healing after prayer. 47 40.9

(27) My spiritual understanding continues to grow. 74 64.3

(28) I am right more often than most people. (disagree/strongly disagree)

34 28.0

(29) Many spiritual approaches have little value. 62 53.9

(30) Spiritual health contributes to physical health. 81 70.4

(31) I regularly interact with others for spiritual purposes.

52 45.2

(32) I focus on what needs to be changed in me, not what needs to be changed in others.

75 65.2

(33) In difficult times, I am still grateful. 91 79.1

(34) I have through a time of great suffering that led to spiritual growth.

51 44.3

The following questions were scored using only the response always or almost always

(35) When I wrong someone, I make an effort to apologize.

95 82.6

(36) I accept others as they are. 75 65.2

(37) I solve my problems without using spiritual resources.

25 21.7

43

Table 7. Continued. Answers reflect Agree or Strongly Agree scores only except for questions that are reverse score negatively worded items. These items were scored disagree or strongly agree.

Frequency Percentage

The following questions were scored using only the response always or almost always

(38) I examine my actions to see if they reflect my values.

49 42.6

The following question was scored 1-7 with “7” being the most spiritual. Scoring for this question used response 5,6,7.

(39) How spiritual a person do you consider yourself? 50 66.9 Table 8. Frequencies and Percentages Questions that Indicated Ratings for General

Health, and Bodily Pain as Self-reported on the Short Form-36 Health Survey questionnaire (N=115).

Questions Frequency Percentage (1) In general would you say your health is:

response: excellent, very good, good 94 81.73

(2) Compared to one year ago how would you rate

your health in general now?

Much better 9 7.83 Somewhat better 18 15.65 About the same 61 53.04 Somewhat worse now 23 20.00 Much worse now 4 3.48

(7) How much bodily pain have you had during

the past 4 weeks?

No response 2 1.74 None 0 0 Very Mild 14 12.17 Moderate 36 31.30 Severe 46 40.00 Very Severe 17 14.78

Additional findings included the increased use of regional analgesic techniques

during the last six months of this research. Concurrent research by another investigator

enrolled some of these same participants receiving total knee arthroplasty in a study using

femoral nerve sheath technique to treat postoperative pain. This investigator examined

44

the pain report outcomes for two of the most frequently used regional analgesia methods

of postoperative pain control: epidurals and femoral nerve sheath catheters. Analysis of

these two methods compared the mean pain scores on postoperative days one, two and

three. Both techniques had lower mean scores for pain scores on days one, two and three

when compared to no regional technique. The epidural provided the lowest mean score

day one (M= 2.74) compared to the femoral nerve sheath on day one (M= 3.17). Those

participants using PRN analgesia and no regional technique had the highest mean pain

score on day one (M=4.25). On day two, the femoral nerve sheath provided the lowest

mean pain score (M==1.82). On day three all of the regional analgesia had been

removed, but the mean pain scores for those persons who received regional analgesia

remained similar to days one and two. On all three days the PRN analgesia group had the

highest mean pain score (Ms= 4.25, 2.90, and 2.94, respectively).

In summary, these findings demonstrated that participants in this study were in

moderate to severe pain and had functional limitations preoperatively, but described

themselves as in good to excellent health and very spiritual. The use of regional

analgesia for postoperative pain control did lower pain scores for all days when compared

to those who did not receive a regional technique.

45

CHAPTER 5 DISCUSSION

The purpose of this study was to examine the relationships between the degree of

spirituality and high scores on a self-health assessment questionnaire with three

postoperative outcomes after hip or knee joint arthroplasty. Specifically, this study

examined the relationships between a high degree of spirituality, a high score for

individual self-health assessment and pain report and analgesic medication use for three

days after total joint replacement surgery. The hypothesized relational statements were

based on the need for quantitative data collection measuring the relationships between

spirituality, health assessment, pain report and analgesic medication use. There is no

previous empirical research that has examined these relationships in the postoperative

arthroplasty patient. The study sample consisted of 115 participants scheduled for hip or

knee arthroplasty in a large Southeastern teaching hospital. This chapter will present a

discussion of (1) research findings, (2) conclusions, (3) research strengths and

weaknesses, and (4) implications for nursing practice.

Research Findings

This section will discuss sample characteristics, followed by study of findings as

they related to the research questions.

Sample Characteristics

One hundred and fifteen older adults who were scheduled for hip or knee total joint

arthroscopy consented to participate in this study. All of the participants were recruited

from the pre-surgical anesthesia center of a large teaching hospital. In this convenience

46

sample, the participant ages ranged from 55 to 86. The average age was 67.70. There

were 41 males and 74 females enrolled in this study. This finding is somewhat less than

the 2:1 ratio females to males in osteoarthritis prevalence as reported by other researchers

(Davis, Ellinger, Newhaus, & Hauck, 1987). Participants described their generalized

body pain as severe or very severe (55%) during the four weeks prior to their scheduled

surgery, but self-assessed their health as excellent, very good or good (81.73%).

Anderson, et al. (1993) and Mobily, et al. (1994) reported similar pain report among older

adults. This research found that functional abilities were severely limited for vigorous

activity such as participating in strenuous sports, lifting heavy objects, vacuuming,

playing golf walking several blocks, bending, stooping and climbing stairs while more

moderate activities such as lifting groceries, bathing and dressing were “limited a little”.

Praemer, Furner, & Rice, (1992) and Salmon, et al. (2001) found similar functional

limitations in osteoarthritis patients.

Ethnicity could not be examined due to the low numbers of African Americans and

Hispanics enrolled in this research. Felson (1988) similarly found that greater numbers

of European whites have osteoarthritis than other ethnicities and this may account for the

differences observed in this study. Only one African American and two Hispanics were

enrolled in this research. Socioeconomic status may have been a factor in the low

number of other ethnic groups seeking joint replacement. However, socioeconomic

status was not considered in this research.

Spirituality, Pain Report and Analgesic Medication.

The first research question examined the relationship of a high degree of

spirituality, postoperative pain scores and analgesic medication use. One research

47

question was used from the SIBS questionnaire. Two groups of participants were created

using one research question from the SIBS questionnaire. Those with high scores for

spirituality were considered highly spiritual. The majority (69.4%) of the respondents

were highly spiritual. A partial correlational analysis was used to identify a relationship

between a participants’ high spirituality and the variables, age, pain report for three days

and analgesic medication use postoperatively, controlling for self-assessed health. There

was no relationship for spirituality and the variables. Therefore, hypothesis 1 was

rejected. Participants who have a high degree of spirituality did not tend to have less pain

and did not tend to use less analgesic medication postoperatively. Although there was a

high participant response to spirituality, the possibility of spiritual coping did not tend to

influence pain or pain medicine use after joint replacement surgery.

Health Self-Assessment, Pain Report and Analgesic Medication Use

It was hypothesized that participants who consider themselves healthy will report

less pain and use less analgesic medication postoperatively. The health variable “In

general would you say your health is: excellent, very good, good” was used to identify

those participants with a high score on health assessment. Of the participants, 81.7%

rated their health in this positive way. Correlation analysis found that persons who

considered themselves healthy tended to have less pain on each day postoperatively but

they did not tend to use less pain medication. Therefore, there was no association

between high health scores and less pain medication use. Further analysis using a partial

correlation controlling for the spirituality variable, found similar results; a healthy

assessment was related to less pain for the three days postoperatively and had no

relationship with the amount of pain medication.

48

In summary, participants who rated self-health as good, very good or excellent

tended to experience less pain during the first three days postoperatively. However, these

same participants did not tend to use less pain medication. Research question 2 was

accepted for less pain, but rejected for less pain medication use.

Impact of Health Assessment and Spirituality on Pain Reports and Analgesic Medication Use

Lastly, it was hypothesized that participants who considered themselves to be very

spiritual and healthy would use less analgesic medication during their postoperative

recovery. A regression analysis was used to determine possible interactions between

health assessment and spirituality and analgesic medication use. There was no

relationship between the variables and pain medication. A further T-Test was used to

determine if there was a difference between the high spirituality and the high self health

assessment groups in analgesic medication use. The T-Test found no mean difference

between the two groups.

Therefore, Hypothesis 3 was not accepted. Those participants who self-rated their

health as good, very good or excellent and considered their spirituality as high did not

tend to experience less pain or use less pain medication than did the other research

participants.

Conclusions

Although participants reported moderate to severe bodily pain and a decrease in

functional activity on a health questionnaire, they considered themselves to be healthy.

There was a relationship between self-health and pain for the first three days after

surgery. It demonstrated that how a person views their health contributes to the amount

of pain they experience after joint replacement. Additionally, less pain experienced did

49

not mean less pain medication used. There has been no previous research evaluating

relationships between how healthy an individual feels and the amount of pain medication

used after surgery. Previous research that has evaluated health status has been with

individuals who were in “poor health” with long-term disability after surgery.

Most participants considered themselves to be highly spiritual and used spiritual

coping methods such as hoping, praying and dependence on a higher power. There is no

previous research that has examined the spirituality and postoperative pain or pain

medication use after joint replacement surgery. Previous research that evaluated

spirituality, health assessment and functional recovery used a very different patient

population. The only similarity was a high degree of spirituality among the older adult

rehabilitation patients (Fitchett, et al. 1999; Kim, et al. 2000; Pressman, et al. 1990). In

my research, most reported that they used spiritual coping methods and behaviors such as

participation in spiritual activities, spiritual writings and prayer. They also believe their

spiritual health contributes to their physical health. The majority of the participants in

this research used these spiritual coping methods. However, there was no evidence that

high self-evaluation for spirituality influenced pain or pain medication use after total joint

replacement surgery.

Strengths and Limitations

Although this research had strengths, it was limited in its methodology. Primarily

it was a convenience sample of pre-operative total joint arthroscopy patients. This

research was impaired by the use of regional anesthesia by the majority of the

participants. These patients received more regional anesthesia techniques for pain control

postoperatively than most other surgical patients. Regional analgesia is an effective

technique in the treatment of post-operative arthroplasty pain. Pain report and

50

medication use for this group of patients were affected by the use of the regional

anesthesia techniques. It was not possible to control for the increase in regional analgesia

techniques during this investigation.

There was an uneven distribution of males and females. This was to be expected,

but did not approach the 2:1 ratio for osteoarthritis found in previous research. There was

no ethnic diversity found in this research and this finding does not represent the ethnic

distribution in the geographic region.

Implications for Nursing Practice and Future Study

There is evidence from this study that these patients requiring total joint

replacement for osteoarthritis have a high degree of spirituality and perceive their health

as good to excellent. They use spiritual coping and behaviors such as prayer, spiritual

activities, and belief that spiritual health influences physical health.

Second, they feel their health is good to excellent regardless of their functional

limitations or pain. This self-assessment of good health contributed to less pain after total

joint surgery, but did not lessen the need for pain medication.

It is important that the clinician recognize that the postoperative patient is

multidimensional in their self-health and their spirituality. This quantitative study did not

support the hypothesis that spirituality decreases pain or pain medication use. This

research did find a relationship between self-assessed good health and decreased pain, but

did not find a relationship in less pain medicine use. This research contributes to the body

of literature evaluating spirituality and health in the older adult.

Future research should include postoperative function and pain using longitudinal

data collection. Assessing joint arthroplasty subjects pre-operatively, one month

postoperatively and at the end of the one-year recovery period would provide long-term

51

data on the relationships between spirituality, self-health assessment, pain and physical

function. Correlating functional longitudinal data with spirituality and health assessment

would provide more pertinent information without interference from postoperative

regional analgesia.

The implications of this study for nursing practice are that the findings of this study

support the use of spirituality and spiritual behaviors by the majority of the participants.

Good to excellent self-health assessment did change the amount of pain these participants

reported after surgery. Nurses should be more at ease in assessing a patient’s spirituality

and self-health. Nurses do have to recognize that how a patient evaluates self-health may

be important in reducing postoperative joint arthroplasty pain.

In summary, evaluating the participants’ spirituality and self-health assessment

found interesting relationships between postoperative pain and analgesic medication use.

Second, these research findings have implications for further future nursing research.

APPENDIX A LETTER OF AGREEMENT

53

APPENDIX B INFORMED CONSENT 08-19-03 TO 07-15-04

55

56

57

58

59

60

61

APPENDIX C INFORMED CONSENT 01-29-04 TO 07-15-04

63

64

65

66

67

68

69

APPENDIX D INFORMED CONSENT 07-16-04 TO 07-15-05

71

72

73

74

75

76

77

78

APPENDIX E THE SHORT FORM-36 HEALTH SURVEY—SPIRITUAL INVOLVEMENT AND

BELIEFS SCALE

79

80

81

82

83

84

85

86

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BIOGRAPHICAL SKETCH

Patricia Anne McNally was born in Waterloo, New York. She graduated from St.

Mary’s Hospital, School of Nursing, Rochester, New York. Pat attended the University

of Florida and received a Bachelor of Science in Nursing in 1981. A Master of Science

in Nursing degree with a specialization in adult and women’s health was received from

the University of Florida in 1999. Ms. McNally’s current nursing specialty area is the

pre-surgical center at the University of Florida. She is a member of Sigma Theta Tau, the

International Honor Society for Nursing.

Ms. McNally’s nursing career has included emergency department staff nursing,

charge nursing, nursing and business administration, and currently advanced nurse

practitioner. She resides in Gainesville, Florida. Pat is the mother of three adult children

and the “Mamasita” to three young grandchildren.